Debond Consent for Braces

Patients Name

First

Last

Date Of Birth

Email

Treatment Start Date

Treatment End Date

Treatment Completion

I confirm that I am satisfied with the outcome of my orthodontic treatment and consent to the removal of my braces.

Retainer type provided (Select one)

Fixed wire retainer (bonded behind teeth)
Removable clear retainer (Essix)
Both fixed wire and removable retainers

Retainer Information & Important Notes

Retainers are required to maintain the corrected position of teeth after orthodontic treatment. A fixed wire retainer supports the front teeth, while a removable clear (Essix) retainer provides additional stability. Use of both is highly recommended to
minimise relapse.

Teeth can move throughout life; long-term (lifetime) retainer wear is required to
maintain results.
No guarantee can be given regarding long-term stability of teeth.
Fixed retainers hold mainly the front teeth and do not prevent all tooth movement.
The bonding may wear or break; if the wire becomes loose, prompt review is required.
Avoid biting hard foods with front teeth, as the bonding may crack or break
Removable retainers help reduce relapse and should be worn as advised
Poor oral hygiene around retainers may lead to decay or gum problems
There is a small risk of retainer breakage, damage, or accidental loss
Choosing only one type of retainer may increase the risk of relapse
Retainers may require repair or replacement over time at additional cost

Consent & Acknowledgement

I understand the purpose and importance of retainers and the need for long-term wear

I understand that using both fixed and removable retainers is recommended to reduce relapse.

I understand that if I choose only one type, my teeth may still move, and I accept this risk

I understand that failure to follow instructions or attend reviews may result in relapse requiring further treatment at additional cost

I understand my responsibility to maintain good oral hygiene and attend regular dental check-ups

I have had the opportunity to ask questions and give my full consent to proceed

Date

Patients Signature

Guardians Signature (If applicable)

Retainer Information & Important Notes

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